Basic Information
| Provider Information | |||||||||
| NPI: | 1407859036 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTAMENTO DE SALUD OFICIAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UDH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2116 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009212116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877537984 | ||||||||
| FaxNumber: | 7877633684 | ||||||||
| Practice Location | |||||||||
| Address1: | CARR 22 AVE AMERICO MIRANDA BO MONACILLO | ||||||||
| Address2: | |||||||||
| City: | RIO PIEDRAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877540101 | ||||||||
| FaxNumber: | 7877633684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 10/04/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATTA | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7877540101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | MHSA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | PR | N | Hospitals | General Acute Care Hospital | Critical Access | 282N00000X | 3 | PR | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 030450011SJ | 01 | PR | SANITARY LICENSE NUMBER | OTHER | 04136 | 01 | PR | STATE CNC NUMBER | OTHER | 3 | 01 | PR | STATE LINCENSE NUM. | OTHER |